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Insurance Terms – Deductible, Coinsurance, Copay – What’s it all About?

Everyone knows there are medical insurance plans, vision insurance plans, dental plans, prescription drug plans, and many more.  When you visit Warrior Eye Care, we always verify your benefits provided by your vision insurance as well as the benefits provided by your medical insurance plan. Many times every day we are billing eye exams and office visits to medical insurance plans because the visit is related to a medical diagnosis or condition, and not defined strictly as routine vision care. When a visit is to be covered by your medical insurance provider, there are three important variables that every patient needs to understand about the insurance policy you have signed up for…..deductibles, coinsurance, and copays.  This article will attempt to explain each one and how they apply.


A deductible is the amount you pay for health care services before your health insurance begins to pay.  For example, let’s say your plan’s deductible is $1500. That means for most services, you’ll pay 100 percent of your medical and pharmacy bills until the amount you pay reaches $1500. After that, you share the cost with your plan by paying coinsurance and copays. If you are seeing the eye doctor for a medical condition, it works just like it does when you see a medical doctor. The charge for the visit will be applied to your medical deductible for that insurance period. So if you have not met your deductible for that insurance year, you will be required to pay out-of-pocket, and that will be reported to your insurance company to give you credit toward your deductible.


Coinsurance is your share of the costs of a health care service. It’s usually figured as a percentage of the amount the insurance company allows to be charged for services. You start paying coinsurance after you’ve paid your plan deductible. Here’s how it works. Lisa has glaucoma, so she sees her eye doctor regularly. She has paid her $1500 deductible for the year ( a combination of everything she has paid for all covered medical visits to all covered providers (medical doctors, eye doctors, pharmacy bills, etc.)  Now her plan will cover 70 percent of the cost of her doctor visits.  Lisa pays the other 30 percent; that’s her coinsurance.


A copay is a fixed amount you pay for a health care service, usually when you receive the service. The amount can vary by the type of service. For example, a doctor’s visit might have a $30 copay. The copay for an emergency room visit will usually cost more, such as $250. For some services, you may have both a copay and coinsurance.


When choosing an insurance plan, how much it costs you every month is just one part of the cost of having the insurance. Think about how much you use your insurance and how much protection you want against unpredictable expenses. Then look at the plan’s deductible, coinsurance and copays, and find what works best for you.

We verify all insurance benefits before your designated appointment time, and try to anticipate each patient’s out-of-pocket expenses prior to each visit. Payment for vision and medical services is expected to be made the day the service is given. You should always come to a doctors office visit prepared to pay your portion of the charges incurred as well as any charges not covered by your insurance policies. By utilizing Care Credit, a healthcare financing program, you can spread the cost of out-of-pocket expenses out over 6-12 months, making convenient monthly payments. We will help you understand your insurance coverage, and can help you understand the flexibility of using Care Credit to cover those out-of-pocket expenses. But what we can’t do is change the deductible, coinsurance or copay built into your insurance policy.